What’s So Wrong with Ritalin

Watch Dr. Pentz discuss misconceptions about stimulant medications.

Two recent articles on the front page of the New York Times Sunday Review have touched a familiar disheartening chord for many of us in the ADHD community. Dr. Alan Sroufe’s “Ritalin Gone Wrong” (1/29/12) followed three weeks later by Hanif Kurieshi’s “The Art of Distraction”(2/19/12), were grim reminders of how much work there still needs to be done to educate the public about Attention Deficit Disorders. There was even a local example of what feels like a media assault on the ADHD community. Two weeks ago WCPO evening news anchor Carol Williams featured a story on the dangers of psychiatric medication for ADHD (and other conditions), ending with the chilling “Medicate as a last resort, doctors say”! It’s hard not to feel like the ADHD community, not just medication, is under siege.

Dr. Alan Sroufe led the attack with a frontal assault on the popular use of Ritalin and other medications prescribed to treat ADHD. Outrage from both the professional community and people with ADHD, as well as national ADHD advocacy organizations like CHADD (Children and Adults with Attention Deficit Disorders) poured out in letters to the NY Times as well as on websites and blogs across the country, complaining – and rightly so – about Dr. Sroufe’s grotesque distortion of the research literature, and his bold assertion that these medications have little to justify their use and are probably unsafe. Sroufe contends that no research study to date “has found any long term benefit”; that medications “work for four to eight weeks”, are “habit forming,” and can have “serious side effects.” He claims their growing use does little except to “feed into the societal view that all of life’s problems can be solved with a pill.” These are all statements that fly in the face of what the research literature actually says and are from a clinician’s perspective a demeaning characterization of the long hard road children and their parents have to travel when treating ADHD.

The truth is that medications for the treatment of ADHD have been extensively studied for the past four decades. There are well over 200 controlled studies demonstrating their safety and effectiveness, more than any other class of psychoactive drugs, and more than most of the medications in your medicine cabinet, including aspirin. If the best of these studies only demonstrate effectiveness over the first year or so, it’s only because 14 months is the longest time frame that any controlled study has been able to observe the direct impact of medication treatment before the study ended.

Dr. Sroufe cites one of the most important studies, commonly called the MTA study, which followed nearly 600 children during 14 months of treatment and included follow-up two years after. The study was well designed and able to compare the effectiveness of medication treatment administered systematically and monitored closely using higher and more consistent doses than typically prescribed by most community medical providers. The study found that medication treatment alone or combined with psychological interventions was by far better than psychological interventions alone or routine community care. When Sroufe claims the positive effects faded, he fails to mention that they faded because the systematic treatment with medication ended after those 14 months (along with the grant used to finance this part of the study)! When he disingenuously states that studies show no positive impact after “four to eight weeks,” he fails to mention that this refers to a very large number of studies – some used to get the original FDA approval for medications – that only had children in the treatment protocol for – yes, you guessed it – four to eight weeks! When a treatment of a chronic condition is effective the positive effects stop when the treatment does. For a more thorough discussion of these and all of the scientific inaccuracies with Dr. Schrouf’s claims, see the excellent summary by Dr. Harold Koplewicz.

As for Sroufe’s statement that using medication is the easy way out for parents, prominent national expert Dr. Ned Hallowell points out in his response to the article that parents almost always agonize about the decision to medicate, and that the process is anything but easy or a reflection of so-called cultural values that seem to solve every problem with a pill. Sroufe suggests that drugs prevent us from addressing the environmental causes of ADHD (which for 20 years have not been shown to be nearly as important as genetically transmitted biological factors), including poverty and the associated risks of “trauma, chronic stress, and other early-childhood experiences”. He goes on to say that even affluent families can produce the conditions giving rise to ADHD: “Especially patterns of parental intrusiveness that involve…for example…[when] the parent picks up [a 6-month old baby] from behind and plunges it into a bath”; or a parent “taunts and ridicules” a “3 year-old becoming frustrated in solving a problem”. Parental intrusiveness? This is what he claims to be at the root of ADHD? Not only is there no data to support this view, but as Judy Warner in Time Magazine eloquently asked, “do we really want to regress to an era of stigma and shame” that existed 40 years ago and blamed parents for ADHD and most psychological disorders? Environment and family life do have an impact of course – that’s why clinician’s know that medication treatment alone is rarely enough – but the results of genetic and twin studies cannot be ignored: ADHD is not caused by environmental factors. To say so is just plain wrong.

I was equally taken aback by the second of the anti-medication one-two punch in the NY Times three weeks later. Hanif Kureishi is a writer ostensibly making a compelling case for embracing the “Art of Distraction”. I actually looked forward to an argument for the power and beauty of letting the art of distraction take people to new and wonderfully creative places. I also found myself initially resonating with his criticism of experts diagnosing his dyslexic son and berating him with a diagnostic assault based on harsh “standardization of a human being and a notion of achievement that is limiting, prescriptive and bullying”. I have seen enough of the same in meetings with educational consultants in my career to have agreed wholeheartedly…until he got to the real point of his article. Then, he lost me. An 18 year old friend of another son – who he condescendingly refers to as “Ritalin Boy” throughout the article – apparently could not convince Mr. Kureishi that his use of Ritalin to help him concentrate at school and stop “falling behind in life” was anything other than a capitulation to “obedience”, a form of “enforcement and psychological policing…the contemporary equivalent of the old practice of tying up children’s hands in bed so they wont touch their genitals”, and a way “the parent stupefies the child for the parent’s good”. The point of the article was supposedly an argument for letting people follow their creative distractions and a hope that the “Ritalin Boy” could let his distractions guide and work for him instead of choosing “obedience over creativity” by taking Ritalin. But is that really the only choice for “Ritalin Boy” and others diagnosed with ADHD? Hardly.

Our experience in working with ADHD children and adults is quite the opposite. Creative distractibility does not disappear with medication. The only thing that disappears is the miserable aspects of struggling to focus when you want and need to. If you have difficulty concentrating in the classroom or while reading due to ADHD (not because your teachers are boring or you’re just having a bad day) it’s because – no matter how badly you desire to – you can not get your brain to engage in something that requires active effort. Not being able to read or engage in conversation with, or actively listen to, someone for any length of time without getting distracted can limit what you learn about the world and relationships in profound ways. Distractions are often just that, and while interesting, they are just as often in the way of the creative process, just as they can be in the way of doing your home work, balancing your checkbook, driving your car, or having a conversation with your son.

Distraction – for its creative potential as well for as its interference in things that people really want and need to do in life – is only one small part of having ADHD, and only one of the areas medication helps. To reduce ADHD to little more than creative distractions makes for a cartoonish simplification of the dozens of ways ADHD interferes with life. It ignores the problems with planning, judging time, and organizational challenges that make it difficult to manage school work to avoid failure or to complete work tasks to avoid losing your job. It ignores other problems with missing details, forgetfulness, losing things, the ability to listen in conversations or communicate effectively, failing to finish and complete things, impulsivity and/or restlessness. Try to make the argument that a creative life requires any of those, and that to take medication to minimize them is conceding to a life of “obedience”. When ADHD is not treated, alcohol and drug abuse are just a couple of the associated difficulties that are also experienced more often. Are those important for the creative life too?

Most creative people I know still need to find a way to start and finish their creative work. They also need to know how to stay attentive and connected to the people in their lives. They need to find pleasure in the simple act of not being constantly bombarded and overwhelmed with a mind that keeps darting from one idea to the next (not all of them good or creative ideas). In over 25 years of treating people with ADHD, I have never encountered anyone who feels that medication to treat their ADHD is similar to having their hands tied behind their backs. Most would say they feel exactly the opposite.

These New York Times articles have the potential to do great public harm. Both Dr. Sroufe, who in retirement seems to be bitter that his long and distinguished career is being undermined by the paradigm shift that establishes as much or more causation for biological determinants of behavior versus the environmental impacts he studied so long (like poverty and bad parenting), and Mr. Kureishi, who just seems bitter, should be ashamed of the distortion and personal prejudice that permeates their articles and undermine the more interesting points they were really trying to make. They both use Ritalin as a metaphor and a scapegoat for what they feel has gone wrong in society (and I suspect in their lives), but I have no doubt that they believe in what they are saying and are unlikely to feel any shame at all. By printing the parent-bashing and fear-mongering criticisms of an effective medical treatment, it seems someone at the editorial desk of the New York Times may also have a personal prejudice against it. If readers question whether to start or continue medication as a result – and I believe that thousands of people across the country could be swayed to do so – then how many people could now turn away from what has been, and can be, a life changing treatment? The opinion pages of the Sunday Review aren’t likely to cause any great harm when the opinions are about politics or current social issues. But when the NY Times prints opinions that undermine the legitimate confidence people can feel in a scientifically supported medical intervention – when the authors were not adequately vetted and the publication of those articles are allowed to stand without the chance for alternative views to be expressed in the same space – then it’s the New York Times that should be ashamed.